HKCC 2433 Basic Health Assessment and Clinical Skills

Neurological Assessment I
Yes No Comments
1. Identify the client (verbal)
2. Wash hands (verbal)
3. Maintain patient privacy (close curtain)
Provide for proper lighting
Assess mental status
Level of consciousness
Thought processes
Appearance and behavior
Speech
Obtain history
Provide for exposure of areas to be examined
Test cranial nerves
4. Cranial nerve I Olfactory (sensory)
 Smell (omit)(verbal)
5. Cranial nerve II Optic (sensory)
 Visual acuity – snellen chart (omit)
(verbal)
 Test for visual field
 Examine with opthalmoscope
6. Cranial nerve III Oculomotor (motor)
 Six cardinal gazes
 Test for fixation and accomodation
 Papillary constriction- direct and
consensus
 Observe for ptosis of upper eyelid
Cranial nerve IV Trochlear (motor)
 Inferior lateral movement of eyes
Cranial nerve VI Abducens (motor)
 Inferior lateral eye movement
7. Cranial nerve V Trigeminal
(sensory and motor)
 Corneal reflex (omit)
 Sensation of skin of the face (eyebrow,
cheeks and chin), using a wisp of cotton
 Motor – chewing, biting, lateral jaws
movement, against resistance
8. Cranial nerve VII Facial
(sensory and motor)
 Taste – anterior 2/3 of the tongue
Sweet/ salt/ sour/ bitter
( omit)
 Motor – movement of forehead and mouth
Raise eyebrows, show teeth,
Smile and puff out cheeks, close eyes tight
and against resistance
9. Cranial nerve VIII Acoustic ( sensory)
 Hearing, balance
 Weber and Rinnie tests
 Whisper test
 Otoscope
10. Cranial nerve IX Glossopharyngeal
(sensory and motor)
 swallowing and phonation (saying ahh)
 taste – posterior 1/3 of tongue (omit)
HKCC 2433 Basic Health Assessment and Clinical Skills

11. Cranial nerve X Vagus

(sensory and motor)
 sensation of posterior 1/3 of tongue, throat
(omit)
 motor – gag reflex
 swallowing and phonation
12. Cranial nerve X Spinal accessory
(motor)
 shoulder movement, shoulder shrug, head
rotation – push against examiner’s hand
13. Cranial nerve XII Hypoglossal (motor)
 tongue movement – protrude tongue, push
tongue into the cheek
 saying sounds of letter l, t, d
(e.g. letter, dinner)

Assess motor system

Muscles (inspect and palpate)
Size
Strength
Tone
Involuntary movements
Assess cerebellar function
14. Balance tests
Gait (including tandem walking)
Romberg test
15. Coordination and skilled movements
16. Rapid alternating movements
(RAM) or
Rapid finger-to-thumb
17. Finger-to-finger test
18. Finger-to-nose test
19. Heel-to-shin test
Assess sensory system
20. Pain—sharp and dull
21. Light touch
22. Vibration
23. Position (kinesthesia)
Tactile discrimination (fine touch)
24. Stereognosis
25. Graphesthesia
Assess reflexes
Stretch, or deep tendon reflexes (DTRs)
26. Biceps
27. Triceps
28. Brachioradialis
29. Quadriceps
30. Achilles (ankle jerk)
31. Plantar
32. Hand hygiene
33. Document findings (verbal)